Adult survivors of childhood abuse have higher rates of illness than are found among the general population—often debilitating illnesses accompanied by chronic pain. Some standard medical treatments are likely to be difficult for survivors, and can even re-traumatize them. Now professionals can turn to this comprehensive resource to get practical advice on working with these challenging and vulnerable patients and specific guidelines for treating the three most common symptoms encountered in health care settings: depression, PTSD and chronic pain.
Get answers to critical questions like these:
- Why and how should clinicians in a primary care setting screen for and treat depression, PTSD and chronic pain?
- What is the link between past abuse and current pain?
- How is past childhood abuse linked to the most common causes of death in adults?
- Why are the healthcare costs of abuse survivors are higher than those of the general public?
- Why are abuse survivors more likely to participate in high-risk sex?
- How can clinicians take care of themselves when working with traumatized patients?
- Which standard medical procedures are more likely to traumatize patients who are abuse survivors?
- Why are a patient’s thoughts and beliefs important in the development of illness?
- What are the AMA Guidelines on treating patients with a trauma history, without further traumatizing them?
- What gastrointestinal symptoms are most common in abuse survivors?
- Why are patients who are hostile or mistrusting more likely to have coronary heart disease?
- When childhood abuse has impact a person’s faith or belief in God, what are the implications of that for health?
Table of Contents
About the Author
Foreword
Preface
Chapter 1: Abuse Survivors in the Health Care System
The Health of Adult Survivors
Patterns of Health Care Use
Doctors’Visits
The Impact of Severity
Symptoms, Surgery, and Disability
Increased Health Care Costs
Depression
Posttraumatic Stress Disorder
Pain
Why Child Abuse Makes People Sick
Chapter 2: Physiological Pathways
The Brain and Nervous System
Brain 101
Brainstem Nuclei
The Stress Response
Sensory Intake and Interpretation of the Environment
Generation of Emotions Based on the Appraisal Processes
Initiation of Autonomic and Endocrine Responses
Autonomic and Endocrine Outflow
Neuronal Plasticity
Sensitization
Changes in the HPA Axis
Evidence for HPA Alterations and Sensitization
Animal Studies
Studies of Infants
Studies of Children
Summary
Chapter 3: Behavioral Pathways
Substance Abuse
Representative Sample of Adults
Samples From Primary Care Medical Practices
Samples From Treatment Programs
Samples With Children or Teens
Other Clinical Populations
Prospective Designs
Possible Explanations for Substance Abuse in Adult
Survivors
Psychosocial Explanations
Biological Vulnerability
How Substance Abuse Affects Health
Smoking
Why Abuse Survivors Smoke
How Smoking Affects Health
Obesity and Eating Disorders
Obesity
Eating Disorders
Theories for Eating Disorders in Abuse Survivors
How Obesity and Eating Disorders Impact Health
Suicide
Relationship Between Abuse and Suicide
The Health Effects of Suicide Attempts
High-Risk Sexual Behavior
High-Risk Sexual Activity Among Special Populations
Theories Explaining High-Risk Sexual Behavior
Cognitive Aspects of High-Risk Sex
Social Learning Theory
Health Effects of High-Risk Sexual Activity
High-Risk Behaviors in Combination
Health-Promoting Behaviors
Sleep
Possible Mechanisms for Sleep Disturbances
Perfectionism and Parental Criticism
Anxiety
Depression
PTSD
How Sleep Affects Health
Summary
Chapter 4: Cognitive Pathways I—Beliefs About Self
Shame and Self-Blame
Shame
Self-Blame
Studies With Teens and College Students
Studies With Adults
Health Effects of Shame and Self-Blame
Attributional Style
Impact of Abuse on Attributional Style
How Attributional Style Influences Health
Health Perception
Health Effects of Health Perception
Health Locus of Control
Self-Esteem and Self-Efficacy
Self-Esteem Influenced by Childhood Abuse
Self Efficacy Influenced by Childhood Abuse
Health Effects of Self-Esteem/Self-Efficacy
Adaptation to Disability
Compliance With Treatment
Health Behaviors
Self-Efficacy and Parenting
Summary
Chapter 5: Cognitive Pathways II—Cognitions About Others
Internal Working Model
Mistrust and Hostility
Mistrust
Hostility
Health Effects of Mistrust and Hostility
Rejection Sensitivity
Rejection Sensitivity and Current Relationships
Rejection Sensitivity and Health
Dependency
Religiosity
Impact of Past Abuse on Religious Faith
Religion and Health
How Religion Can Positively Influence Health
How Religion Can Negatively Influence Health:
Anger at God
Forgiveness
Hope
Impact of Abuse in Hope
Hope and Health
Summary
Chapter 6: Social Pathways I—Social Networks, Support, and
Relationships
Attachment Theory Revisited
Insecure Attachments
Abuse as Predictor of Attachment Style
Health Effects of Insecure Attachment
Quality of Current Primary Intimate Relationship
Divorce
Social Isolation
Impact of Relationships on Health
Social Support Buffers Stress
Marriage, Marital Strife, and Health
Social Isolation and Health
Childhood Abuse and Interpersonal Style
Dysfunctional Interpersonal Styles
Relationship of Interpersonal Style to Health
Unmitigated Communion
Caretaking
Attachment Style
Relationships
Why Social Support Is Sometimes Stressful
Summary
Chapter 7: Social Pathways II—Poverty, Homelessness, and
Revictimization
Socioeconomic Status
Difficulties in School
Learning Difficulties in Adults
SES and Health
Unhealthy Behavior
Psychosocial and Psychobiological Factors
Homelessness
History of Adverse Experiences
Teens and Homelessness
Health Implications of Homelessness
Revictimization
During Childhood
Of Young Adults and College Students
Of Adults
Community Samples
Clinical Samples
Family Dysfunction Increases Risk
Revictimization in Ethnic-Minority Populations
Theories of Revictimization
Revictimization and Health
Summary
Chapter 8: Emotional Pathways—Posttraumatic Stress Disorder
Depression and Abuse Survivors
Prevalence
Co-Occurring Depression and Substance Abuse
Is Child Sexual Abuse Uniquely Harmful?
The Biology of Depression
Sensitization and Depression
Depression and HPA Alterations
Cholinergic Pathways in Depression
Depression and Cytokine Activity
How Depression Influences Health
Depression and Cardiovascular Health
Depression and Immune Function
Depression and Health Behaviors
Depression and Increased Vulnerability
Posttraumatic Stress Disorder
The Biology of PTSD
Dysregulation of Stress Response
Effects of PTSD on the Brain
How PTSD Affects Health
Mechanisms by Which PTSD Influences Health
PTSD and Comorbidity
PTSD and Reactivity
PTSD and Sleep Quality
PTSD and Health in Aging Trauma Survivors
PTSD vs. Depression
Summary
Chapter 9: Individual Differences in the Expression of Symptoms
Timing of Abuse, Brain Maturation, and Appraisal of Events
Brain Maturation
Critical Periods of Brain Development
Sensitization Revisited
Appraisal
Characteristics of the Abuse
Identity of the Perpetrator
Severity of Abusive Acts
Duration and Force
Ethnic Group Differences in How Abuse Is Experienced
Sex of Subject and Symptomatology
Quality of the Family of Origin
Independent Effects of Abuse vs. Family Dysfunction
Family Dysfunction Compounds Effects of Abuse
Family Dysfunction Also Increases the Risk of Abuse
Summary
Chapter 10: Chronic Pain in Abuse Survivors
The Enigma of Chronic Pain
Difficulties in Diagnosis and Treatment
Functional vs. Organic Conditions
The Pain-Abuse Connection
Psychiatric Comorbidity in Pain Patients
Explanations for Psychiatric Diagnoses in Functional Illness
Chronic Pain vs. Somatization
Treatment Impact of Somatization
Neurological Mechanisms in Pain
Brain Structures in Pain
Changes in the Pain Threshold
Chronic Pain Syndromes in Adult Survivors of Childhood Abuse
Back Pain
Headaches
Pelvic Pain and Other Gynecological Conditions
Pelvic Pain
Other Gynecological Conditions
Fibromyalgia Syndrome
Effects of Past Abuse on Development of FMS
Pathophysiology of Fibromyalgia
Sleep Problems in Fibromyalgia
Irritable Bowel Syndrome
A Diagnosis of Exclusion Associated With a History of Abuse
Some Theories of Irritable Bowel Syndrome
What We Know About Pain and Abuse
Pain Syndromes Co-Occur
Pain Syndromes Have Commonalities
We Still Cannot Prove That Abuse Causes Chronic Pain
Summary
Chapter 11: Clinical Approaches to Abuse Survivors in Health Care
Settings
When to Suspect Past Abuse
How to Inquire About Past Abuse
Routine Screening
Clinician Concerns When Screening
Why Abuse Survivors May Deny Abuse
Trust Issues
Possible Amnesia
Handling Abuse History When Patients Share It
Charting Abuse Information
Maintaining Confidentiality
Assessing Current Patient Safety
Other Legal Obligations
Duty to Report
Duty to Warn
Treating Without Traumatizing: Approaches to Patients in Medical Settings
Using a Medical/Mental Health Team Approach to Care
Finding Clinicians in the Community
Identifying Comorbid Psychological Conditions
Use of Support Groups
Summary
Chapter 12: Clinical Management of Depression in Health Care Settings
Assessment of Patients for Depression
Depressive Symptoms
Diagnostic Criteria for Major Depression
Risk Factors for Depression
Past Depression
Current Stressors
Family History
Lack of Social Support
Psychiatric and Physical Comorbidity
Assessing Active Substance Abuse
Assessing Suicide Risk
Assessing the Need for Psychiatric Hospitalization
Treatment With Antidepressant Medications
Major Types of Antidepressants
Tricyclics
Selective Serotonin Reuptake Inhibitors
MAOIs
Phases of Depression Management With Medication
Acute Phase
Continuation Phase
Maintenance Phase
Antidepressants and Breastfeeding Mothers
Cognitive-Behavioral Therapy
Efficacy of CBT for Abuse Survivors
Alternative Treatment Approaches
Supplements
Exercise
St. John’s Wort
Summary
Chapter 13: Clinical Management of Posttraumatic Stress Disorder
Diagnosis of PTSD
Initial Screening
Diagnostic Criteria for PTSD
Complex PTSD
Treatment
Patient Education
Normalization
Removing Self-Blame and Self-Doubt
Correcting Misunderstandings
Clinician Credibility
The Efficacy of Patient Education
Peer Counseling
Psychotherapy
Cognitive-Behavioral Therapy
Eye Movement Desensitization and
Reprocessing
The Efficacy of Psychotherapy
Medications
Antidepressants
Benzodiazepines
Adrenergic Agents
Anticonvulsants
Phases of Treatment With Medications
Summary of Treatment for PTSD
Chapter 14: Basic Pain Management in a Health Care Setting
Why Pain Is Difficult to Treat
Management of Chronic Pain
Assessment
Treatment Team
Barriers to Treatment
Pharmacological Treatment of Chronic Pain
Non-Steroidal Anti-Inflammatory Drugs
Narcotics
Antidepressant Medications
Nonpharmacological Management of Chronic Pain
Relaxation Techniques
Progressive Muscle Relaxation
Biofeedback
Cognitive Aspects of Pain Management
Patient Education
Pain Diary
Activity Pacing
Pleasant-Activity Scheduling
Addressing Beliefs About Pain
Reframing or Cognitive Restructuring
Physical Treatments
Physical Therapy
Chiropractic and Acupuncture
Practitioner Misbeliefs About Chronic Pain
Some Final Suggestions for Clinicians
Summary
Epilogue
Table of Acronyms
Appendix A: Treatment of Traumatized Children
Appendix B: Online Resources for Depression
Appendix C: Online Resources for Posttraumatic Stress Disorder
Appendix D: Online Resources for Pain
Appendix E: Clinical Self-Care
Appendix F: Bibliography
Index